Reading of the Week: Cannabis Legalization – Clinical Implications & Major Papers

From the Editor

It’s legal.

After decades of debate, Canada has legalized recreational marijuana, joining an exclusive club of nations with just one other member: Uruguay.

In the coming weeks, many details will be sorted out – some small (the regulation of edibles), some not so small (driving and use). But starting this week, we clinicians work in a different world.

What are the clinical implications of legalization? Will we see more use? How will people present to our EDs and clinics? What should we ask on a history? And how do we treat cannabinoid hyperemesis syndrome? (Spoiler alert: ginger stat.)

In the first selection, I highlight comments by CAMH’s Dr. Jonathan Bertram made in an interview with me. We discuss what every clinician should know about legalization.

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And then with an eye on the journals, I pick a few essential articles on cannabis, drawing from The New England Journal, JAMA, and other major publications, considering topics from the adverse effects of marijuana to the implications for pain management.

DG

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Reading of the Week: Weight Loss for People with Schizophrenia? STEPWISE Didn’t Work. On the Big Paper, the Not-So-Big Result & Negative Results

From the Editor

Years ago, I worked with a patient who lost 70 pounds with an aggressive regiment of exercise. His determination was exceptional but his struggles with obesity weren’t. People with schizophrenia are twice as likely as the general population to deal with weight problems.

In the first selection, we consider a paper on weight loss for those with schizophrenia and related illnesses. STEPWISE offered these patients a thoughtful approach to weight management. The paper is remarkable for its finding: the intervention didn’t work. As the University of Southampton’s Dr. Richard I. G. Holt and his co-authors write: “the intervention was neither clinically nor cost-effective over the 12-month intervention period.”

In this Reading, we consider the paper, but also the larger issue of negative trials and their lack of presence in the literature.

bank-failure-lw-schwenk-locWe often read about bank failures; medical study failures, not so much

In the second selection, we draw on a New York Times essay by pediatrician Aaron E. Carroll who calls for the publication of more negative trials. “These actions might make for more boring news and more tempered enthusiasm. But they might also lead to more accurate science.”

DG

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Reading of the Week: Social Media & Paranoia — the new Acta Paper; Also, How Do We Change Docs? A Reader Responds

From the Editor

Politicians tweet about townhall meetings; celebrities put vacation pictures on Instagram; your cousin in Europe has her own YouTube channel.

Our world is very different than it was just a few short years ago. (Fun fact: Facebook – a decade and a half old – claims to have more than 2 billion active monthly users.)

But how has social media affected those with mental illness? While this is much discussed in the media, there is little in the literature. In this week’s Reading, we consider a new paper that looks at social media and mental illness, in particular psychosis. Tweet this: the University of Manchester’s Natalie Berry and her co-authors didn’t find a connection between use of social media and increased paranoia.

BELCHATOW POLAND - MAY 02 2013: Modern white keyboard with colored social network buttons.

In this week’s Reading, we consider this new paper from Acta Psychiatrica Scandinavica. We also wonder about the role of the Internet and social media for those with psychosis, drawing from a Psychiatric Services paper.

Also, the University of Toronto’s Dr. Ivan Silver writes a letter to the editor about a previous Reading.

DG

 
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Reading of the Week: Do Antidepressants Beat Placebo? Does Measurement-based Care Work? Four Papers and Some Thoughts on a Fourth Anniversary

From the Editor

This month, the Reading of the Week – in its present form – turns four.

Today, the Readings are emailed out from sea to sea to sea. It’s a big evolution from the first Readings, started more than six and a half years ago, with me handing out photocopies of papers on the inpatient ward where I worked.

To celebrate our silk anniversary, I’ve picked four major selections from the past four years. I’ve also included some papers that haven’t been discussed – but should have been.

p9180013Silk: good for a fourth wedding anniversary, but a fourth Reading anniversary?

Enjoy.

DG

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Reading of the Week: How to Change Docs? Send Them a Letter. The New JAMA Psychiatry Paper on Prescribing

From the Editor

How do we get doctors to practice better medicine?

Here’s a simple idea: what if we send them a sternly written letter? In this week’s Reading, we consider a paper by Columbia University’s Adam Sacarny and his co-authors who did just that. Targeting primary care physicians who were heavily prescribing quetiapine (or Seroquel), they looked at the effects of letters written by government officials, comparing prescribing habits of these physicians with their peers. The result? In the new JAMA Psychiatry paper, they find that prescriptions of quetiapine dropped markedly.

nudge

A little nudge, better care?

The core of the idea is that a nudge – that is, the behavioural economic idea of a positive reinforcement and/or an indirect suggestion – can change outcomes. In this Reading, we consider doctors and nudges (and behavioural economics). We also look at a recent study on opioid prescribing, also involving letters.

DG

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Reading of the Week: Physician Burnout and Depression – and Patient Safety. New Papers from the AJP and JAMA Internal Medicine

From the Editor

Not so many years ago, no one seemed to discuss physician burnout.

Today, we speak much more about physician health and wellness.

In this week’s Reading, we consider a new American Journal of Psychiatry paper written by Dr. Erick Messias and Victoria Flynn of the University of Arkansas for Medical Sciences. In this highly readable Clinical Case Conference, the authors discuss the case of a mid-career psychiatrist – and then weigh the larger problem of burnout, and its overlap with depression.

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Also, we consider the literature around burnout, and highlight a new JAMA Internal Medicine paper. “The pooled outcomes of the main analysis indicated that physician overall burnout is associated with twice the odds of involvement in patient safety incidents (OR, 1.96…).”

DG

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Reading of the Week: ECT & Dementia – the New Lancet Psychiatry Paper

From the Editor

It’s effective but is it really safe?

Electroconvulsive therapy (ECT) remains controversial 80 years after its first clinical use. At the heart of the controversy: its effects on cognition. Some wonder about the possibility that ECT could be linked to dementia.

Despite the strong concerns expressed over the years, relatively little research has been done on the possible connection between ECT and dementia. This week, we consider a new paper by the University of Copenhagen’s Merete Osler and her co-authors. In this Lancet Psychiatry study, they tap Danish national databases, finding no connection.

old-man-in-sorrow-vincent-van-goghvan Gogh’s Old Man in Sorrow – in need of ECT?

In this Reading, we look at the paper and consider some recent work on ECT.

DG

 

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Reading of the Week: Appointment Letters & Focused Therapies – Thinking Outside the Box

From the Editor

When we speak of improving the quality of mental health care, we often think about cutting-edge innovation – wearables, virtual reality, genetics, to name a few things.

This week, there are two selections. Both discuss innovations aimed at improving care – but neither could be considered particularly “cutting edge.”

In the first selection, researchers sought to improve outpatient appointment attendance with a decidedly low-tech idea: appointment letters reminding patients of the importance of follow up. Spoiler alert: it worked.

In the second selection, drawn from The New York Times, reporter Andrea Petersen discusses clinics that use a short, intense version of CBT.

Thinking outside the box

Together, these two selections illustrate some thinking outside the box.

DG

 
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Reading of the Week: Antidepressants after Acute Coronary Syndrome and Depression – A Lifesaver? The New JAMA Paper

From the Editor

State-of-the-art care for acute coronary syndrome includes oxygen and clot-busting drugs. Should it also include a depression screen and an antidepressant if necessary?

In this week’s Reading, we look at a new JAMA paper showing a response to escitalopram for patients post-ACS (Acute Coronary Syndrome) with depression. Though work has been done in this area before, this paper is an important contribution: it’s well designed, and offers a long follow-up period. Chonnam National University Medical School’s Jae-Min Kim and his co-authors conclude: “In this median 8.1-year follow-up of a randomized 24-week clinical trial of treatment for depression in patients with recent ACS, MACE [major adverse cardiac event] incidence was significantly lower in patients receiving escitalopram than those receiving placebo.”

We consider the paper and its implications.

norm_2xGood EKG, good antidepressant?

Please note that there will be no Readings for the next two weeks.

DG
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Reading of the Week: Mental Illness & Crime Victimization – the New JAMA Psychiatry Paper

From the Editor

After the mass shooting on Toronto’s Danforth, mental illness has been much in the news. The Canadian Psychiatric Association went so far as to warn against stigmatizing those with mental illness.

Despite stereotypes, studies show that people with mental disorders are more likely to be victims of violent crime rather than perpetrators. That said, the literature is light on how much crime patients experience, and the diagnoses of these patients.

This week, we look at a new paper just published by JAMA Psychiatry. Drawing on databases from Denmark, the University of New South Wales’ Kimberlie Dean and her co-authors consider crime (including violent crime) in a cohort study involving more than two million people. What do they find? Those with mental illness are much more likely to be victims than the general population.

gettyimages-126140612_superDenmark: old buildings and not-so-old data

In an accompanying editorial, Duke University School of Medicine’s Jeffrey W. Swanson and Charles M. Beldendiscuss the paper, and contrast it with American data. Their piece begins memorably: “The media-driven notion that mentally ill people pose a danger to others appears to be encrusted like a barnacle on the concept of mental illness submerged in the public mind.” They also weigh in on difference in rates of violence between Denmark and the United States.

DG

 

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